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Management Guideline for Influenza A-H1N1 for Pediatric Patients
 

Case definition  

A confirmed case of  novel influenza A(H1N1) in children is defined as a child (< 12 years old) who has influenza-like illness (fever ≥ 38 °C with cough and/or sore throat) and confirmed positive laboratory tests either by real-time PCR or viral culture.
 

Signs and Symptoms

Most influenza A(H1N1) infection in children are mild and self-limiting. The common symptoms on presentation are fever ≥ 38 0C (100%) and cough (100%), sore-throat (66%), myalgia (44%), vomiting and diarrhea ( 25%). Other uncommon presentations are  altered conscious level (10%) or hypotension or sepsis-like picture. (Mexico and U.S case series)

Only 10% of  influenza A(H1N1) infection require admission. The two most common reasons for admission are pneumonia and dehydration.

Mild cases of Influenza-like illness do not need admission and no investigations are needed. (Refer Appendix 1. Home Assessment Tool)

For children nursed at home, they will need to be monitored daily by parents or guardian for appearance of new symptoms or worsening of symptoms that suggest complications.


Criteria for admission

Children with influenza-like illness (fever ≥ 38 °C with cough and/or sore throat) with moderate to severe disease as listed as below:

Severe respiratory distress Lower chest wall indrawing, sternal recession, grunting, or noisy breathing when calm.

Increased respiratory rate. Measured over at least 30 seconds. ≥50 breaths per minute if under 1 year, or ≥40 breaths per minute if ≥1 year.

Oxygen saturation 92% on pulse oximetry, breathing air or on oxygen. Absence of cyanosis is a poor discriminator for severe illness.

Respiratory exhaustion or apnoeic episode Apnoea defined as a ≥20 second pause in breathing.

Evidence of severe clinical dehydration or clinical shock Sternal capillary refill time >2 seconds, reduced skin turgor, sunken eyes or fontanelle.

Altered conscious level Strikingly agitated or irritable, seizures, or floppy infant.

 Other clinical concerns e.g. a rapidly progressive or an unusually prolonged fever or persistent diarrhea or vomiting

Hospitalization

Once admitted, all hospitalized patients (those with moderate to severe disease) with confirmed or suspected novel influenza A H1N1 should be started on antiviral treatment. (Table 2, 3 & 4) The antiviral treatment maybe stopped if the RT-PCR results are negative.

Observations include conscious level, respiratory rate, Sp O2 and vital signs monitoring. Frequency of monitoring is as per clinical judgement.

Patients admitted with moderate to severe disease with co-morbid factors (Table 1) should be observed more closely as they may have more severe and rapid progression of disease.


Table 1 : List of co-morbid factors
  • cardiac disease
  • chronic respiratory disease (eg asthma,bronchopulmonary dysplasia)
  • other chronic diseases (e.g., diabetes, chronic metabolic diseases, chronic renal failure, haemoglobinopathies)
  • chronic neurological disorders e.g. muscular dystrophies.
  • impaired immunity, including HIV infection, child with malignancy or immunosuppressive therapy
  • children aged 6 months – 10 years on long-term aspirin therapy
  • malnourished or obese

Respiratory specimens that are taken to diagnose InfluenzaA-H1N1 infections are nasopharyngeal aspirate or nasal / throat swab. These specimens are taken under full PPE.

Care-givers who look after their children should be given a 3-ply surgical mask. Visitors should be limited to caregiver only.

Criteria For Discharge Of Paediatric patients

 For children admitted to hospital with Influenza A-H1N1 (confirmed case), he or she can be discharged if :

  1. He/she had completed 5 day course of oseltamivir.
  1. If need arise for the child to be discharged earlier, he/she can be discharged after completing 3 days (or 6 doses) as long as the child does not have complications, afebrile for  the last 24 hours and not from the high risk group. The need for early discharge is reviewed, on a case by case basis if required.

For all children who have been discharged, they need further home isolation for a total of 7 days from ONSET of illness (including the time of admission). 

Post exposure chemoprophylaxis in children.

Chemoprophylaxis is indicated for close contact who fulfill the following criteria:

  1. Children < 2 years old with co-morbidity (Refer Table 1). AND
  2. Within 48 hours of close contact with a confirmed index patient. 
Close contact are defined as those  living in the same house / premise (household contacts) and those who have sustained close contact (< 3feet) for at least 4 hours.

Recommendation for Home Assessment for Pediatric patients  

For children nursed at home, child need to be monitored daily by parents or guardian for appearance of new symptoms or worsening of symptoms that suggest complications.  

Drugs used in treatment and prophylaxis for children 

Most commonly used anti-viral for influenza is oseltamivir. Duration of chemoprophylaxis is for 10 days (daily dose) and for treatment 10 days (BD dose)

The reported side effects are gastrointestinal i.e. nausea, vomiting and abdominal pain. These side effects may be mitigated by administration with food. There are limited data on the use of oseltamivir in children less than 12 months of age, studies in older children had shown  oseltamivir to be effective in treatment of seasonal flu by reducing duration of symptoms. Use of oseltamivir was also associated with a reduction in the incidence of antibiotic use and lower respiratory tract infections.  
 

Table 2. Antiviral medication dosing recommendations for treatment or chemoprophylaxis of novel influenza A (H1N1) infection. 

Agent, group

Treatment

Chemoprophylaxis

Oseltamivir

Children ≥ 12 months

15 kg or less

90 mg per day divided into 2 doses

30 mg once per day

16-23 kg

120 mg per day divided into 2 doses

45 mg once per day

24-40 kg

150 mg per day divided into 2 doses

60 mg once per day

>40 kg

300 mg per day divided into 2 doses

75 mg once per day

Zanamivir

Children

Two 5-mg inhalations (10 mg total) twice per day (age 7 years or older)

Two 5-mg inhalations (10 mg total) once per day (age, 5 years or older)

 Antiviral Usage in children below 1 years old

Children under one year of age are at high risk for complications from seasonal human influenza virus infection. The characteristics of human infection novel (H1N1) influenza virus are still being studied, and it is not known whether infants are at higher risk for complications associated with novel (H1N1) influenza virus infection compared to older children and adults. Oseltamivir is not licensed for use in children less than 1 year of age. However, limited safety data on oseltamivir treatment for seasonal influenza in children less than one year of age suggest that severe adverse events are rare.  

Tables 3. Dosing recommendations for antiviral treatment of children younger than 1 year using oseltamivir.

Age

Recommended treatment dose for 5 days

<3 months

20 mg twice daily

3-5 months

25 mg twice daily

6-11 months

30 mg twice daily


Table 4. Dosing recommendations for antiviral chemoprophylaxis of children younger than 1 year using oseltamivir.

Age

Recommended prophylaxis dose for 10 days

<3 months

Not recommended unless situation judged  
critical due to limited data on use in this age group

3-5 months

20 mg once daily

6-11 months

25 mg once daily

Management of critically ill patients

Rapidly progressive respiratory failure is relatively common preceding ICU admission.

Early intubation seems to improve the outcome.

Profound hypoxaemia is common and may persist for 48-72 hour on antiviral before improving.

Ventilation strategies used for ARDS  may include low tidal volume 4-6ml/kg, high PEEP and pressure control. Inline suction should be used for ventilated patients. Adequate sedation is important to suppress high ventilatory drive – requirement for neuromuscular blockade is common. Prone positioning can be used and nitric oxide may be helpful.

Aim for SpO2 of about 85% and accept permissive hypercapnia as long as pH is > 7.25.

Serial monitoring of lactate is helpful to assess adequacy of end-organ function.

Moderate hypotension is relatively common. Most patients respond to fluid +/- vasopressor therapy; however volume expansion should be undertaken with caution as over-hydration seems to worsen outcome and as a result a conservative fluid strategy is recommended.

Monitor for other end-organ dysfunction as well.

Use of immunoglobulin and intravenous hydrocortisone/methylprednisolone are controversial. However, they may be considered in severe refractory cases.

Use of H2 receptor antagonist is advised in patients treated with steroid.

Antibiotic should be started for ventilated patients to cover for superimposed bacterial infection such as staphylococcus aureus , streptococcus pneumoniae or Group A streptococcus. Cloxacillin, amoxicillin-clavulanate and cefuroxime can be used.

Special Circumstances

Postpartum women who are not ill with influenza should be encouraged to initiate breastfeeding early and feed frequently. Women with influenza-like illness are recommended to use facemasks when providing infant care and feedings. Hand hygiene and cough etiquette (cover nose and mouth during coughing/sneezing) must be practiced at all times.

Babies born to infected H1N1 mother can be discharged home if they are asymptomatic and clinically well. However , in this situation mother will have to be advised regarding the home assessment tool (Appendix 1.)

Infection control guidelines
Standard infection control principles and droplet precautions must be practiced by all health care staff dealing with patients who have or are suspected of having influenza.

Hand Hygiene

  • Health care workers and visitors must perform hand hygiene regularly, including when removing gloves.
  • Patients with Influenza like illness (ILI) should be encouraged to perform hand hygiene frequently.

Personal protective equipment
Personal Protective Equipment (PPE) – Advice for use during Procedures (including Collection of Swabs for Influenza Diagnosis) 

  • Health care workers should routinely wear a surgical mask, protective eyewear and disposable gloves if they are undertaking an examination of an individual with ILI that may lead to coughing (e.g. collecting nose and/or throat swabs).
  • All health care workers in the same room when aerosol-generating procedures are undertaken on ILI patients should use N95 respirators, protective eyewear, a disposable gown and disposable gloves. Aerosol-generating procedures include endotracheal intubation, nebulized medication administration, airway suctioning, bronchoscopy, diagnostic sputum induction, positive pressure ventilation via face mask, and high frequency oscillatory ventilation. These procedures should only be performed in a single room with the door closed.
  • Administration of medication via nebulisers is not recommended. Use spacers where possible.
Table 5.  Use of Personal Protective Equipment (PPEs)
 
Entry to cohorted area but no contact with patients
Close Contact with patient (within 3 feet)
Aerosol generating procedures ° (see Reference 1 below)
Gloves
No °°
Yes
Yes
Plastic Apron
No °°
Yes
Yes
Gown
No
No
Yes
Surgical Mask
Yes**
Yes
No
N95 mask#
No
No
Yes
Eye Protection
No
Risk Assessment@
Yes

In- Patient Isolation

  • Single room isolation can be used for influenza AH1N1 inpatients and people with ILI presenting in clinical settings, wherever possible.
  • If single rooms are not available, cohorting of influenza AH1N1 patients should be practised wherever possible.

Management of Visitors

  • Limit visitors for patients who are in isolation to those persons who are necessary for the patient's emotional wellbeing and care. Visitors should also be masked and instructed on hand hygiene policies.

Housekeeping
Normal cutlery and plates can be used for H1N1 patients in the isolation room. Disposables are not required.

Appendix I

Home Assessment Tool for Parents and Caregivers 
For children nursed at home, they need to be monitored daily by parents or guardian for appearance of new symptoms or worsening of symptoms that suggest complications.  

Children should be brought to the nearest hospital for further assessment if they developed the following symptoms and signs:  

1-Lethargy or poor oral intake
2-Change in mental status or behavior eg. drowsiness , irritability
3-Signs of dehydration: sunken eyes, dry tongue, absence of tears during crying or poor urine output.
4-Increasing respiratory rate: fast breathing, noisy breathing, presence of chest recession (chest in-drawing)
5-Fits.
6-Cyanosis.
7-Persistent fever > 3 days.

Appendix 2. List of equipment needed for management of H1N1 Patients

No.

Item

Numbers

a.

Volumetric infusion pumps

1 every 2 beds

b.

Syringe pumps

1 every 2 beds

c.

Drip Stands

1 every 2 beds

d.

Digital Thermometer
OR

1 per bed with 10% spares

Ear Thermometer

1 per 8 beds

e.

Pulse oximeter

1 per 4 beds

f.

O2 analyser

1 per 12 beds

g.

Low-flow O2 flowmeters

1 per 4 beds

h.

High-flow O2 flowmeters

i) Acute bay: 1 for every bed.
ii) Non acute bay: 1 per 4 beds

i.

MDI Spacer device

1 per bed

4 channel vital sign monitors (1 per 4 patients)
End tidal CO2 monitor
Ventilators
Beds
Stethoscope
Defibrillators
Emergency trolley
Procedure trolley

Consumables

Inline suction catheter
Bacteria and viral filter
Disposable ventilator tubings
Disposable laryngoscope and ambu-bag

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